Minnesota Uniform Credentialing Application Reappointment Physician/Dentist/Allied Health Professional

Transcription

1 Minnesota Uniform Credentialing Application Reappointment Physician/Dentist/Allied Health Professional Applicant Name: Last First Middle Suffix Title CREDENTIALING CONTACT INFORMATION Name Address Phone Number Fax Number This Box to be completed by Allied Health Professionals Only Profession/Title Sponsoring/Collaborative Physician (If applicable) Instructions The recredentialing application and attachments should be typed, legibly printed in black ink, or electronically generated. If more space is needed than provided on the application, please attach additional sheets and reference the question being answered. Please do not use abbreviations when completing the application. Please mark all non-applicable sections with N/A. Please verify that you have: Provided complete street addresses wherever indicated, including past employment, hospital affiliations and references Designated dates by month and year time frames Answered all of the Disclosure Questions on Pages 7 and 8 and enclosed explanations for affirmative answers Signed and dated the Authorization and Release (Page 10) All Information Must Be Printed in Black Ink, Typed or Electronically Generated Reappointment Application - September 2001; Revised April 2002; April 2004, January 2006, July 2006, January 2007, August 2011 Page 1 of 15

2 Personal Data Name: Last First Middle Suffix Title Maiden/Former/Other Name(s): Date of Birth: / / Social Security Number: NPl: Medicaid Number: State Medicare Number: State Current Home Street City/State/Country Zip Code Preferred Mailing Office Home Practitioner s Preferred address: Pager Number: Home Do you speak a language other than English with sufficient fluency to treat patients who speak only that language? If yes, specify languages: Primary or Pending Practice Location Primary Practice Location: Office Federal Tax ID Number: Type II NPI: Currently practicing at this location? Start Date: Do you intend to practice as: Primary Care Specialist Urgent Care Locum Tenens Moonlighting Resident Is over 50 percent of your practice primary care? Primary Specialty: Subspecialty: Specialty/Subspecialty in which care will be provided: Provide a narrative description of your clinical practice including special interests (if additional space is required, attach a separate sheet): Additional Practice Location(s) Since Last Reappointment Other Practice Name: Federal Tax ID Number (if different from primary): Credentialing Contact: Type II NPI: Currently practicing at this location? Start Date: If yes, will you continue to practice at this location? If no, last date of employment: Specialty/Subspecialty in which care will be provided: Reappointment Application - September 2001; Revised April 2002; April 2004, January 2006, July 2006, January 2007, August 2011 Page 2 of 15

3 Fellowship/Post-Graduate/Professional Training Since your last reappointment (Month and year required) Institution Name: Type of Program/Specialty (transitional, rotating, 5th pathway, etc.): Completed Training: If no, expected completion date: If not successfully completed, explain: Program Director: Professional and Academic/Faculty Affiliations - Since your last reappointment (Month and year required) Institution Name: Appointment Held/Position: Chronological Employment/Practice History (include Military Service) (Additional space is provided on the Chronological Employment/Practice History Addendum. You may make extra copies of page 13 for additional employments.) Chronological listing [month/year] of employment/practice history since your last reappointment. List all experience, including military service and public health, time out of medical practice in pursuit of other business or professional activities, sabbaticals, parenting, personal travel, personal crisis, etc. LEAVE NO GAPS IN CHRONOCLOGY. (Month and year required) Organization Name/Activity: Reason for Leaving: Contact Name: Clinic Still Open? If no, attach sheet listing address and phone number of someone who can verify your time there. Organization Name/Activity: Reason for Leaving: Contact Name: Clinic Still Open? If no, attach sheet listing address and phone number of someone who can verify your time there. Reappointment Application - September 2001; Revised April 2002; April 2004, January 2006, July 2006, January 2007, August 2011 Page 3 of 15

4 Explain gaps/interruptions of greater than three (3) months to practice of medicine/professional practice - since your last reappointment (if additional space is required, attach a separate sheet): Explain: Explain: Primary Hospital Affiliation (pertinent to Primary or Pending Practice Location listed on page 2) If no hospital admitting privileges, describe method/coverage for continuity of care. Please provide covering physician s name, if applicable. (Month and year required) Admitting Privileges: Type/category of privilege/affiliation (active, courtesy, etc.): Department Name: Department Chairperson: Application Pending Other Hospital Affiliations - Since your last reappointment (Additional space is provided on the Hospital Affiliation Addendum. You may make extra copies of page 13 for additional affiliations.) (Month and year required) Admitting Privileges: Type/category of privilege/affiliation (active, courtesy, etc.): Department Name: Department Chairperson: If hospital changed name, list current name and address Application Pending If hospital changed name, list current name and address Admitting Privileges: Type/category of privilege/affiliation (active, courtesy, etc.): Department Name: Department Chairperson: Application Pending Reappointment Application - September 2001; Revised April 2002; April 2004, January 2006, July 2006, January 2007, August 2011 Page 4 of 15

5 Specialty/Subspecialty Certification Primary Specialty: Board Name: Secondary Specialty: Board Name: Additional Specialty: Board Name: Additional Specialty: Board Name: Check here if you have additional specialty on attached Specialty and Licensure Addendum (page 14) If not certified, please state your intent for certification and describe the status of your efforts and eligibility, including scheduled date of exam, past failures of written or oral exams, if any. Licensure - List all past, current and pending professional licenses. State License Number Date Issued Expiration Date License Status Check here if you have additional licensure on attached Specialty and Licensure Addendum (page 14) Reappointment Application - September 2001; Revised April 2002; April 2004, January 2006, July 2006, January 2007, August 2011 Page 5 of 15

6 Drug Enforcement Administration Registration NOTE: Address on DEA certificate must be in state where you will be practicing as applicable to this application. DEA Number: State: Expiration Date: / / Approved for all schedules?, please explain DEA Number: State: Expiration Date: / / Approved for all schedules?, please explain If you do not maintain a DEA certificate, please explain: Not applicable to practice DEA certificate pending; date application submitted to DEA: / / (Attach copy of application) Other Check here if you have additional DEA s on attached DEA, State Controlled Substance and Liability Insurance Addendum (page 15) State Controlled Substance Certification/Registration (If applicable - not applicable to MN, WI, ND). Issued By: Number: Expiration Date: / / Issued By: Number: Expiration Date: / / Issued By: Number: Expiration Date: / / Check here if you have additional State Controlled Substance Certificates on attached DEA, State Controlled Substance and Liability Insurance Addendum (page 15) Liability Insurance - Insurance Carrier for Primary and Pending Practice Location Enclose a copy of professional liability insurance coverage (e.g., face sheet/verification of self-insurance) for primary practice location to include effective dates, insurance carrier, expiration date, coverage limits, and name of each provider covered. If additional space is required, attach a separate sheet. Coverage dates: Start: / / Insurance Carrier Name: Expire: / / Certificate Pending Name in which policy issued: Policy number: Amount of coverage (per occurrence): Amount of coverage (per aggregate): Check here if you have additional Liability Insurance on attached DEA, State Controlled Substance and Liability Insurance Addendum (page 15) Continuing Education Attestation Please read the following attestation carefully before signing and dating the statement. I hereby certify that I have a sufficient number of CE credits to meet the licensure requirements and attest that an appropriate percentage relate to my specialty. I understand that these credits may be audited by an individual facility based on their individual requirements. Signature: Date: Name: (please print or type) Reappointment Application - September 2001; Revised April 2002; April 2004, January 2006, July 2006, January 2007, August 2011 Page 6 of 15

7 Professional/Peer References List three (3) professional peers who have personal knowledge of your current (within the past 12 months) clinical skills, abilities, judgment, professional performance, and clinical competence or have been responsible for professional observation of your work. A peer is defined as an individual in the same professional discipline with essentially equal qualifications (MD and DO are considered equivalent; DDS/DMD for DDS/DMD; DPM for DPM; PhD for PhD, etc.) Limit to one (1) current office associate. Do not include your residency director, fellowship director, relatives, or pending partners. At least one reference should be in your specialty (and if possible from the same subspecialty). Provide current and complete addresses. References will be evaluated according to the extent of their direct clinical observation of your work and other knowledge of you. Name: Title: Name: Title: Name: Title: Life Support Certification Do you have any current life support certifications (BLS, CPR, ACLS, ATLS, etc.)? If Yes: Type of Certification Expiration Date(s) Immune Status Information for Reappointment Please provide immunity status by completing the question below. DATE OF LAST PPD/MANTOUX: Results: Signature: Date: Reappointment Application - September 2001; Revised April 2002; April 2004, January 2006, July 2006, January 2007, August 2011 Page 7 of 15

8 Disclosure Questions for Reappointment Credentialing Please provide a complete explanation if any of the following questions is answered in the affirmative. Use a separate sheet to continue, if necessary. 1. In the past three years, has your professional license or registration been terminated, stipulated, restricted, limited, conditioned, suspended, revoked, refused, voluntarily relinquished or not renewed by any licensing board or any health-related agency organization, or is there a review pending? 2. In the past three years, has your professional license or registration been investigated or is it currently being investigated and, if so, what were the results? 3. In the past three years, has your DEA registration been revoked, suspended, limited, or conditioned in any way, or have you voluntarily relinquished your DEA registration, or is there a review pending? 4. In the past three years, has your membership, participation, clinical privileges, or employment been denied, terminated, stipulated, restricted, refused, limited, suspended, revoked, or not renewed by any peer review organization, third party payer, clinic, hospital, medical staff, or any health-related agency or organization, or is there a review pending? 5. In the past three years, have you voluntarily relinquished your membership, participation, clinical privileges or request for privileges, employment, professional license, or registration in lieu of disciplinary action, or prior to or during an investigation into your professional conduct or competency? 6. In the past three years, have you involuntarily relinquished your membership, participation, clinical privileges or request for privileges, employment, professional license or registration? 7. In the past three years, has your membership or fellowship in any professional organization or your specialty board certification been voluntarily or involuntarily denied, terminated, restricted, limited, suspended or revoked? 8. In the past three years, have you been reprimanded, censored, or otherwise disciplined by, or have you ever been subject to a corrective action agreement/plan with any licensing board, peer review organization, third party payer, clinic, hospital, medical staff, or any health-related agency or organization? 9. In the past three years, has your certificate or participation in any private, federal (i.e. Medicare, Medicaid, etc.) or state health insurance program been revoked or otherwise limited or restricted, or is any investigation or proceeding with respect to any such action presently underway? 10. Are there any charges pending or are you currently charged with or have you, in the past three years, pled guilty, been indicted or found guilty of a felony, gross misdemeanor, misdemeanor (other than a minor traffic violation), or other offense? Reappointment Application - September 2001; Revised April 2002; April 2004, January 2006, July 2006, January 2007, August 2011 Page 8 of 15

9 11. In the past three years, have you been found liable, guilty or responsible for sexual impropriety or misconduct or sexual harassment with a patient, co-worker, or other? 12. In the past three years, have you ever had any professional liability claims or lawsuits brought against you, including pending claims or lawsuits, dismissed or dropped claims or lawsuits, settlements or final judgments? If yes, please complete the enclosed Malpractice Litigation and Professional Complaints Addendum. You may be asked for additional information by individual organizations. 13 In the past three years, has your professional liability carrier refused or canceled your coverage or excluded you from performing any specific privileges within your specialty? 14. In the past three years, have you practiced within your profession without professional liability insurance? 15. In the past three years, have you had a physical or mental condition that would affect your ability, with or without reasonable accommodation, to provide appropriate care to patients and otherwise perform the essential functions of a practitioner in your area of practice without posing a health or safety risk to your patients? If yes, what accommodations would help you provide appropriate care to patients and perform other essential functions? 16. Does your use (or have you been told that your use) of alcohol or drugs affect your ability, with or without reasonable accommodation, to provide appropriate care to patients and otherwise perform the essential functions in your area of practice without posing a health risk to your patients? If yes, what accommodations would help you provide appropriate care to patients and perform other essential functions? 17. Are you currently using illegal drugs? (Currently means sufficiently recent to justify a reasonable belief that the use of drugs may have an ongoing impact on ones ability to practice medicine. Illegal use of drugs refers to drugs whose possession or distribution is unlawful under the Controlled Substances Act, 21 U.S.C. sec It does not include the use of a drug taken under supervision by a licensed health care professional, or other uses authorized by the Controlled Substances Act or other provision of Federal law. The term does include, however, the unlawful use of prescription controlled substances.) Notice of Applicant s Rights You may review your application and information from publicly available documents at any time during the verification process. This does not include documents protected by hospital policy and/or applicable state laws. If there are discrepancies in the information received during the process, you will be notified and allowed an opportunity to add information to your application. Attestation Signature and Date I hereby certify that all the information on this application form is complete, true and accurate. I further agree to update this information as necessary so that it remains complete, true and accurate while my application is being processed. Signature Date: Name (please print or type) Reappointment Application - September 2001; Revised April 2002; April 2004, January 2006, July 2006, January 2007, August 2011 Page 9 of 15

10 Application Attestation Update The signature blocks below are to be signed ONLY if a previous completed application is being reviewed and updated. Application Attestation Update The application was designed so that a practitioner need complete it in its entirety only once. If application is then made to another organization which accepts this Initial Credentialing Application and it has been more than 60 days since the practitioner completed or updated the application, the practitioner may do the following: Review the application Make any needed modification Sign one of the attestation blocks below, reconfirming that the application is complete, true and accurate. Please note: It is particularly important that the Disclosure Questions be reviewed and any changes made with appropriate documentation included. Update Attestation Signature and Date I have reviewed and updated all of the information on this application, including the Disclosure Questions, and I certify it is complete, true and accurate. Signature Date Update Attestation Signature and Date I have reviewed and updated all of the information on this application, including the Disclosure Questions, and I certify it is complete, true and accurate. Signature Date Update Attestation Signature and Date I have reviewed and updated all of the information on this application, including the Disclosure Questions, and I certify it is complete, true and accurate. Signature Date Reappointment Application - September 2001; Revised April 2002; April 2004, January 2006, July 2006, January 2007, August 2011 Page 10 of 15

11 Authorization and Release (Please read carefully before signing) I understand and acknowledge that, as an applicant for membership, participation and/or clinical privileges (hereinafter, referred to as Participation ) at hereafter referred to as Entity), it is my responsibility to provide sufficient information upon which a proper evaluation can be undertaken of my current licensure, relevant training and/or experience, current competence, health status, character, ethics and any other criteria adopted by the Entity for Participation. I further acknowledge that I am responsible for knowing the contents of the applicable bylaws, rules and regulations, and requirements of the Entity and its professional/medical staff/network, and agree to be bound by them in the application process and if granted Participation. I further understand and acknowledge that the Entity, its designated agent(s) and/or other authorized representatives, including, without limitation, the Entity s designated professional credentials verification organization (CVO), collectively referred to as Agents, will investigate the information in this Application. By submitting this Application, I agree to such investigation and to the disciplinary reporting and information exchange activities of the Entity and its Agents as follows: 1. Authorization of Investigation and Release of Information Concerning Application for Participation. I authorize the Entity and its Agents to consult with any third party who may have information bearing on my professional qualifications, credentials, clinical competence, character, mental condition, physical condition, alcohol or chemical dependency diagnosis and treatment, ethics, behavior, or any other matter reasonably having a bearing on my qualifications for Participation and authorize such third parties to release such information to the Entity and its Agents. 2. Authorization of Release and Exchange of Disciplinary Information. I hereby further authorize any health care organization at which I have applied for, currently have or had Participation or employment to release Disciplinary Information about any disciplinary action taken against me to the Entity and/or its Agents, including, without limitation, the CVO, and as otherwise may be required by law. I hereby further authorize the CVO to release Disciplinary Information about any disciplinary action taken against me to its participating entities at which I have Participation, and as otherwise may be required by law. As used herein, Disciplinary Information means information concerning (i) any action taken by such health care organizations, their administrators or their medical or other committees to revoke, deny, suspend, restrict or condition my Participation or impose a corrective action plan; (ii) any other disciplinary actions involving me including but not limited to discipline in the employment context; or (iii) my resignation prior to the conclusion of any disciplinary proceedings or prior to the commencement of formal charges but after I have knowledge that such formal charges are contemplated and/or in preparation. 3. Release from Liability. I hereby further release from liability the Entity and its Agents, state licensing board(s), health care organizations, including, without limitation, hospitals, clinics, and third party payers, medical malpractice insurance carrier(s), and any staff, and all individuals, institutions and entities providing information in accordance with this authorization, for their acts performed in good faith and without malice in connection with the gathering and release and exchange of information as consented to above. This release shall be in addition to any other applicable immunities provided by law for peer review activities. I understand that communication regarding my application may occur via . I understand and agree that this Authorization and Release is irrevocable for any period during which I am an applicant for Participation at the Entity, or I am a member of Entity s medical or health care staff, or a participating provider of the Entity. I agree to execute another consent if law or regulation limits the application of this irrevocable authorization. Failure to promptly provide another consent may be grounds for termination or discipline of the Participant by the Entity in accordance with the applicable bylaws, rules and regulations, and requirements of the Entity. I acknowledge that the investigation of information in this Application and the release and exchange of Disciplinary Information by the Entity and its Agents are done to achieve, maintain and improve quality patient care. All information provided by me in the Application is true to the best of my knowledge and belief. I understand and agree that any material misstatement in or omission from the Application may constitute grounds for denial or revocation of Participation. I understand and acknowledge that the Entity shall be solely responsible for all decisions concerning the granting of Participation. I further acknowledge that I have read and understand the foregoing Authorization and Release. A photocopy of this Authorization and Release shall be as effective as the original. Signature Date Name (please print or type) Reappointment Application - September 2001; Revised April 2002; April 2004, January 2006, July 2006, January 2007, August 2011 Page 11 of 15

12 Malpractice Litigation and Professional Complaints Addendum Confidential Information If you answered yes to disclosure question #12 on Current Disclosure question page, please complete the following form. For each lawsuit or complaint, please furnish the following and attach a copy of the complaint including your response to the complaint and level of participation. It is your responsibility to provide external verification (i.e., statement from an attorney, court records, etc.) of your response. You may choose to have your attorney complete this form. Please make additional copies of this form if needed. Month/Year of incident: / Reported to National Practitioner Data Bank (NPDB): Where incident occurred: Facility Name Address City State Zip Describe the nature of incident (Complaint, Allegation) - Do Not Include Patient Name or Identifiers: Provide a narrative description of your participation/level of care: Outcome of incident: CONCLUDED WITH NO PAYMENTS: (month/year) CONCLUDED WITH PAYMENTS: (month/year) Dropped/Closed Verdict for you Dismissed with prejudice*? Date: / Date: / Date: / Dismissed without prejudice**? Date: / Verdict for plaintiff Date: / Amount $ Settled Date: / Amount $ PENDING: Date of filing Date: / *Dismissed with prejudice - set aside the lawsuit and deny the right to file another suit on that same claim **Dismissed without prejudice - set aside the lawsuit but leave open the possibility of another suit on the same claim Represented by Legal Counsel for this claim/malpractice lawsuit? If yes, give the name and address of counsel. Name: Insurance company or employer that provided coverage for this claim: Name: Policy Number: Applicant Signature Date Print Name Phone Number Reappointment Application - September 2001; Revised April 2002; April 2004, January 2006, July 2006, January 2007, August 2011 Page 12 of 15

13 Chronological Employment/Practice History Addendum (Please make as many extra copies as necessary) (Month and year required) Organization Name/Activity: Reason for Leaving: Contact Name: Clinic Still Open? If no, attach sheet listing address and phone number of someone who can verify your time there. Organization Name/Activity: Reason for Leaving: Contact Name: Clinic Still Open? If no, attach sheet listing address and phone number of someone who can verify your time there. Hospital Affiliation Addendum (Please make as many extra copies as necessary) (Month and year required) Admitting Privileges: Type/category of privilege/affiliation (active, courtesy, etc.): Department Name: Department Chairperson: If hospital changed name, list current name and address Application Pending If hospital changed name, list current name and address Admitting Privileges: Type/category of privilege/affiliation (active, courtesy, etc.): Department Name: Department Chairperson: Application Pending Reappointment Application - September 2001; Revised April 2002; April 2004, January 2006, July 2006, January 2007, August 2011 Page 13 of 15

14 Specialty/Subspecialty Certification Additional Specialty: Specialty and Licensure Addendum (Please make as many extra copies as necessary) Board Name: Additional Specialty: Board Name: Additional Specialty: Board Name: Additional Specialty: Board Name: State Licensure State License Number Date Issued Expiration Date License Status Reappointment Application - September 2001; Revised April 2002; April 2004, January 2006, July 2006, January 2007, August 2011 Page 14 of 15

15 DEA, State Controlled Substance and Liability Insurance Addendum (Please make as many extra copies as necessary) DEA Certificates DEA Number: State: Expiration Date: / / Approved for all schedules?, please explain DEA Number: State: Expiration Date: / / Approved for all schedules?, please explain DEA Number: State: Expiration Date: / / Approved for all schedules?, please explain DEA Number: State: Expiration Date: / / Approved for all schedules?, please explain State Controlled Substance Certificates Issued By: Number: Expiration Date: / / Issued By: Number: Expiration Date: / / Issued By: Number: Expiration Date: / / Issued By: Number: Expiration Date: / / Liability Insurance Start: / / Insurance Carrier Name: Expire: / / Certificate Pending Name in which policy issued: Policy number: Amount of coverage (per occurrence): Amount of coverage (per aggregate): Start: / / Insurance Carrier Name: Expire: / / Certificate Pending Name in which policy issued: Policy number: Amount of coverage (per occurrence): Amount of coverage (per aggregate): Start: / / Insurance Carrier Name: Expire: / / Certificate Pending Name in which policy issued: Policy number: Amount of coverage (per occurrence): Amount of coverage (per aggregate): Reappointment Application - September 2001; Revised April 2002; April 2004, January 2006, July 2006, January 2007, August 2011 Page 15 of 15